Radiology: An ounce of planning goes a long way in curbing vascular interventional radiology errors

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An observation study has determined that failures during vascular interventional radiology (VIR) procedures are most often attributed to ineffective planning, communication errors or equipment difficulties, not technical skill or patient-related issues, according to an article published online June 5 in Radiology.

Since many of these failures are preventable, preprocedural team rehearsals (PPTRs) could be a way of minimizing frequent preventable failures, according to study authors Colin D. Bicknell, MD, and colleagues from Imperial College, London.

“If the findings from this study in our center are typical of other centers, it seems a large proportion of potential failures that occur during successful VIR procedures are preventable and a simple PPTR can achieve significant reductions in the rate of failures, thereby improving efficiency and safety,” wrote the authors.

Bicknell and colleagues assessed the frequency of errors at their facility by recording field notes during 55 VIR procedures, then having two blinded assessors review the notes and identify failures. These failures were then categorized by error type using a 22-part classification system.

During this phase of the study, 1,197 potential failures were recorded, with 54.6 percent classified as preventable. Planning error was the most frequent category of error at 19.7 percent. Other common error types included staff absence (16.2 percent), equipment unavailability (12.2 percent), communication error (11.2 percent) and lack of safety consciousness (6.1 percent). Taken together, this list of the most frequent error types accounted for 65.4 percent of the total.

The researchers then designed and implemented PPTR which targeted frequent preventable failures. Another 33 procedures were observed after PPTR was implemented.

Among the procedures conducted after intervention, there were 352 potential failures recorded. The rate of preventable failures decreased to 27.3 percent, with potential failures per hour falling from 18.8 to 9.2.

“Although a large number of potential failures were observed, all procedures were successful and few major failures were observed,” wrote the authors. “The clinical effect of the minor failures observed is difficult to quantify; many will remain latent, but a small failure at a critical point in the procedure or an accumulation of small failures may lead to a substantial event. At the very least, these failures will lead to procedural delays and inefficiency.”

Bicknell et al looked at the specific error categories to try and understand their causes. They had expected the number of potential failure to increase with procedure length, and this turned out to be true, though there was no evidence of failures clustering at specific time intervals, with the observed errors occurring throughout the procedure.

Somewhat counterintuitively, there was not a strong correlation between case complexity and the number of potential failures. The authors suggested this underscores the fact that failures are not simply because of a lack of technical skill or related to patient- or procedure-specific characteristics.

Staff absences were largely accounted for by equipment unavailability, explained Bicknell et al. “Equipment unavailability appeared to be related to poor preprocedural planning. Such errors were deemed to be preventable, and it was thought that improved planning, by implementation of a PPTR, would enhance teamwork, communication, and equipment availability, thereby reducing absence and procedural delays.”